We criticize alternative medicine for not being evidence-based, and they criticize conventional medicine in turn, saying that much of what conventional medicine does is not based on evidence either. Sometimes that criticism is justified. I have run across a conventional practice that I suspect began because it sounded like a good idea, but that never was adequately tested and is not carefully thought out for individual patients.
I recently had a bone marrow aspiration. The written instructions said not to eat or drink for 6 hours before the procedure, to bring someone to drive me home, and to expect an IV. I suspected from these instructions that they were planning to use IV sedation, and I was right.
I questioned the need for sedation. I am prejudiced about bone marrow aspirations. I observed several and did one myself during my internship. When I had finished, the patient asked me when I was going to start. We did the procedure at the patient’s bedside in a multi-bed ward with no sedation, only local anesthesia. So my prejudice was that the procedure was no big deal and was not terribly painful.
I can imagine that some patients may be terrified by the idea of a needle going into their bone and may want to be sedated and not remember the experience. But I was not anxious about it, and I saw no need for the fentanyl and Versed they wanted to give me. I figured it would only prolong my time in the hospital, produce amnesia, expose me to a small risk of adverse effects, and leave me groggy; so I asked to opt out. They readily agreed – although they did keep asking me if I was really sure I didn’t want it. They would not have offered the option of no sedation if I had not known to ask.
The pathologist doing the procedure told me the injection of local anesthetic into the skin was the most painful part of the procedure. He was wrong. It was the ONLY painful part of the procedure. The penetration of bone and the aspiration of marrow produced only a pressure sensation.
This study reported that 85% of non-sedated patients had intense pain. I find that hard to believe, based on my personal experience and the experience of the pathologist that the local anesthetic was the worst part of the procedure. I wonder if those patients were anxious and were expecting intense pain. At any rate, I think giving me IV sedation would have been the wrong thing to do.
I had a similar experience with an excisional breast biopsy. They offered me general or local anesthesia and I chose local as presumably the safer option. Then they said they would use IV sedation along with the local. I asked why. They said to relieve anxiety. I told them I wasn’t anxious so if that was the only reason for sedation, I didn’t want it. I finally prevailed. I was comfortable, alert, had a good time chatting with the anesthesiologist, and was able to leave the recovery room much sooner than sedated patients.
I’m not saying that IV sedation is not indicated for some patients, but I am convinced it was not indicated for me. Has it become a knee-jerk reflex to sedate everyone as a general principle? Why? To avoid complaints and keep patients more cooperative during procedures? Are we paternalistically deciding that it is better if the patients don’t remember the procedure? I wonder: if minor procedures are not remembered, might the mystery increase anxiety and fear of the unknown for future procedures? We must ask seriously whether IV sedation is done more for the patient’s benefit or the doctor’s. The answer will vary with the procedure and the patient.
Rather than sedating every patient, why not use some judgment? Even if the patient is anxious, perhaps a non-drug option could relieve that anxiety without risking the side effects of drugs. Surely some anxiety is due to fear of the unknown. Would it help to show patients a video of someone comfortably undergoing the procedure without sedation, with an explanation of exactly what was happening? Would simple reassurance or personal attention from a patient advocate be helpful? Worth looking into? I think so.
Doctors are frequently accused of prescribing unnecessary drugs out of habit or reflex. I suggest that IV sedation for minor procedures is an example of over-prescription that is based more on custom than on good evidence.
*This blog post was originally published at Science Based Medicine.*